This week the White House unveiled its new national plan to cut HIV infections and curb the AIDS epidemic. The plan, the first ever since AIDS emerged on the scene some 30 years ago, has the goal of  "intensifying HIV prevention efforts in communities where HIV is most concentrated;” specifically in the gay and African-American communities who are disproportionately affected by the disease. It also aims to increase access to treatment and mount "a more coordinated national response to the HIV epidemic."

Some specific goals from the National AIDS Plan include:

• Reduce new infection rates by 25 percent by 2015.
• Devote $30 million from the health care reform law to reducing infection rates.
• Link 85 percent of those who are HIV-positive to care within three months of being diagnosed.
• Provide $25 million in funding to help states pay for drugs to treat HIV

This plan, which took 15 months to draw up and included input from 14 community forums around the country, is a good start and helps put the fight against AIDS back on the national radar. Some 1.1 million Americans are currently infected with HIV and infection rates haven’t budged since the mid-1990s. After hitting a peak of 130,000 new infections a year in the 1980’s, the rate dropped to 49,000 a year in the early 1990’s, according to the Centers for Disease Control. But in the past decade this number has increased and remains at 56,000 new infections each year. Meanwhile, in 1995, 44% of Americans indicated that HIV/AIDS was the most urgent health problem facing the country; in March 2009 that number had plummeted to only 6%.

The complacency about AIDS partly results from the advent of better drugs that keep patients healthy and alive longer. But it also stems from the marginalized nature of the groups that bear the greatest brunt of the epidemic: young gay men, African-Americans and intravenous drug users. The irony of Obama’s plan though, is that although it purports to shift more of the $19 billion in domestic funding for HIV/AIDS to these populations, only 4% of this funding is currently spent on prevention and only $25 million is being funneled to states to help pay for their important AIDS Drug Assistance Programs (ADAPs).

These are state-administered programs that provide free HIV-related medications to the 183,000 individuals living with HIV and AIDS (and the tens of thousands more who in these tough economic times are projected to soon need these services). Those who qualify for ADAPs are lower-income people who are uninsured or have very little prescription drug coverage. It costs ADAPs over $1,100 for a year’s worth of just the antiretroviral drugs used by one HIV-positive individual.

The $25 million the plan provides for these programs is just a drop in the bucket, says Brandon Macsata, CEO of the ADAP Advocacy Association, an organization that aims to increase treatment access for persons living with HIV/AIDS. The federal-state ADAPs are facing a $126 million shortfall for fiscal year 2010, just to keep pace with demand.

This shortfall is not unexpected. According to the National Alliance of State and Territorial AIDS Directors, “the federal share of the national ADAP budget has been declining from a high of 68 percent in 2000 to the current share of 49 percent. Over that same time, state revenues for ADAPs have increased to help meet program demands. However, the economic downturn is now forcing states to decrease or eliminate their state support of ADAP as well as other care and treatment programs. In FY2008, states contributed $329 million, or approximately 20 percent, of the overall ADAP budget. In FY2009, the state share fell to approximately 14 percent.”

What that means is that now some 2,300 HIV-positive people have been placed on ADAP waiting lists. Macsata says he is hearing from many of them and they are “fearful and angry.” And, he continues, the 2,300 “are just the tip of the iceberg. States are restricting eligibility and we may soon be looking at 10,000 HIV-positive people not receiving their medications.”

In Ohio, for example, 1,000 of the 5,000 people receiving ADAP benefits are losing access to free AIDS medication, and hundreds more with AIDS are losing other benefits like dental care, other medications and emergency help with rent and utilities. The problem in that state (which is typical of others), according to a recent article in the Cleveland Plain Dealer is that “As people lost their jobs or found themselves down-sized, more and more turned to the program for help.

“On top of that, rising drug costs used up more of the program's money.

“‘We are in an unfortunate situation largely due to the economy,’ [Jay] Carey [management analyst for Ohio’s Ryan White Program] said in a phone interview Friday. ‘There's not enough resources.’”

“Without the cutbacks, the program would have had a $16.4 million deficit at the end of this fiscal year, Carey says. With the cuts, the program should end up with a zero deficit, he says.”

The long-term goal is that under Medicaid expansion starting in 2014, the majority of those currently receiving medications and services under ADAP will be covered under public insurance. Those uninsured people with incomes up to 400% of the Federal poverty level (about $43,000 for a single individual in 2010) will have access to Federal tax credits and can purchase private insurance coverage through the insurance exchanges. New consumer protections will prevent insurers from discriminating against subscribers based on health status and pre-existing conditions.

But right now, there is a clear crisis occurring with ADAPs and the shiny new National Plan does not address it. Besides the pain and suffering experienced by HIV-positive individuals who will have to forgo their life-saving antiretroviral drugs, under-funding ADAPs can have serious public health consequences. According to work done by Brian Williams, an epidemiologist at the South African Centre for Epidemiological Modelling and Analysis, when people take antiretroviral drugs the concentration of  virus in their bodies drops by a factor of 10,000, thereby reducing their risk of  passing on the infection by 25 times. In this case, effective treatment is also good prevention.

The solution to the ADAP problem is tricky. Democrats want to provide $126 million in emergency funding to states for the programs as part of their economic recovery plan that is stalled in Congress. Republicans—who also support ADAPs—want that money to come out of stimulus funding that is already appropriated. Meanwhile, the cutbacks continue and people suffer.

In the end, the release of the nation’s first AIDS strategy is promising. It refocuses efforts on prevention, redistributes funds to groups and regions that really need them, and will hopefully lead to a more effective and concerted effort to stem this terrible disease. But we must make sure that in the short-run we are not abandoning the very people we purport to help; the vulnerable groups who depend on ADAP for their medications.